Patient Treatment Process – Case Study

Follow A Patient Through Treatment

This case demonstrates the incredible abilities we routinely harness using the most current technology and our approach to treatment planning which emphases smile and facial aesthetics and treatment simplicity. I am thankful to her and her family for allowing me to show you her treatment.Our treatment plan, using state-of-the art, low-force, low-friction systems, involved no extractions. Our goal was to not only make her teeth straight, but equally important, to enhance her smile and facial aesthetics now and for the future. I also wanted to put as little hardware in her mouth as possible, reduce her appointments to the office, and finish quickly.

Before starting treatment, this patient obtained another orthodontic opinion. The other opinion recommended the removal of four permanent teeth. In fact, she was told that a non extraction approach would push her front teeth forward excessively, be unaesthetic, and would fail.My opinion was that extractions, while dentally very reasonable, would negatively affect her face and smile by retracting her teeth and lips excessively. Thinning her lips would be an aesthetic problem that would only worsen as she got older. You should not harm facial aesthetics to align the teeth.However, a non extraction approach using conventional braces without the use of auxiliary expanders would very likely excessively flare her front teeth and not be aesthetic. Expanders could make her treatment non extraction, but would put her through more orthodontic gadgets. I was also concerned that an expander may tip her back teeth too much toward her cheeks and perhaps compromise the gum support on the cheek side of her back teeth.

Pretreatment photos:
Note how her gums are receding at the arrows, the extreme crowding, and narrow dental arches. Very importantly, note the angle from the tip of her nose to her upper lip and the relationship between her lips, nose and chin. Her teeth are not touching on both sides.

10 weeks into treatment:

This photo was taken at the first adjustment appointment. Note how the teeth straighten so quickly. No unfavorable side effects using very comfortable forces even though no teeth were removed to make space for the crowding.

Five months in treatment:

At this point only 5 months into treatment at the second adjustment you can already see incredible changes. The arches are widening and a more normal arch shape is starting to form. This has been accomplished with wire as flexible as fishing line and without the use of auxiliary expansion devices. Also note how the gums at the arrows are actually improving with the treatment. Look at her face and smile. Her smile is already improving and her lip position is slightly fuller. Notice her front teeth from the side view, they have tipped forward only slightly which has actually improved her lip relationship.

Eight months in treatment:

The gums around the teeth that were deflected wide before treatment now appear completely normal. Her bite has closed in the presence of a significant tongue problem without any elastics to bring her teeth together.

Her teeth have straightened dramatically even though significant detail is still required. If she had gone no further than this, her treatment would already be a success. This is the point in treatment where I wanted to look at the angulation of her front teeth from a side x-ray. She has had some forward tipping of her front teeth which you can see in the photo. But are her teeth tipped to an unaesthetic angle? I don’t think so. Her smile is even better than before and the position of her lips to her nose and chin is even better than before.

Progress x-rays:

Note in the highlighted area the angulation of the front teeth and the relationship between the teeth and lips. The top photo is the pretreatment x-ray and the bottom photo is nine months into treatment. At this point using only comfortable low-force, small diameter round wires the front teeth have moved forward. However, given the magnitude of bite correction the front teeth and the lips are quite nicely positioned.

Starting elastics:

The remainder of treatment involved enhancing the details of alignment and elastics to further tighten the biting relationship. The braces were adjusted to enhance the shape of the dental arches, further upright the front teeth, minutely detail the positions of the teeth, and enhance her smile and facial aesthetics.

Final Results:

The post treatment photos show the teeth aligned, and the front and back teeth nicely upright. Both arches have been expanded across the bicuspid region. Even more importantly, her smile follows the contours of her lips, and her teeth are positioned well into her face without straining her lips.

The side x-ray shows her front teeth nicely angulated and positioned.

The photo taken with Dr. Oppenhuizen (below) immediately after her braces were removed.
Her smile says it all…

This case demonstrates how important it is to diagnose and treat for facial and smile aesthetics. Also, this case highlights the advantages of using the latest state of the art bracket system to develop the arches, align the teeth and keep the teeth positioned well within the jaw bones.